PARTICIPATING HEALTH CENTER
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Health Center Name
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System will pre-populate
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Grant/Look alike Number
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System will pre-populate
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PATIENT DETAILS
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Total Patients (UDS Definition)
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System will pre-populate
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Number of Patient Charts in EHR
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Number of Sites (Baseline)
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Number of Sites (Current)
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COHORT 1 (FY2012 and FY2013): ANSWER AT LEAST 1 HEALTHY PEOPLE
2020 MEASURE
COHORT 2 (FY2016): ANSWER AT LEAST 5 HEALTHY
PEOPLE 2020 MEASURES
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HP 2020 Measure
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Not Met
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Met
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Exceeded
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N/A
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Comments (Maximum 1000 characters)
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Access to Prenatal Care (First Prenatal Visit in 1st Trimester)
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Childhood Immunizations
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Cervical Cancer Screening
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Colorectal Cancer Screening
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Dental Sealants for Children
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Low Birth Weight
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Hypertension BP Control (BP < 140/90)
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Diabetes Control (HbA1C > 9%)
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Other (e.g. asthma, tobacco use screening, tobacco cessation)
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PCMH RECOGNITION
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[_]No Recognition
[_]TJC
[_]AAAHC
[_]NCQA Level 1
[_]NCQA Level 2
[_]NCQA Level 3
[_]Other (If Other, then Specify):
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EHR AND HIT IMPLEMENTATION STATUS - COHORT 1(FY 2012 AND FY 2013)
AND COHORT 2 (FY 2016)
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1. Does the participating health center use an ONC- ATCB certified
E.H.R. (if implemented, what was date of implementation)?
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[_] Yes [_] No
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2. How many sites have the EHR system in use?
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MEANINGFUL USE - COHORT 1(FY 2012 AND FY 2013) AND COHORT 2 (FY
2016)
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1. Have the eligible providers in participating health centers
registered and attested/applied for EHR Incentive Program
payments?
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[_] Yes [_] No
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2. Have the eligible providers in participating health centers
received EHR Incentive Program payments?
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[_] Yes [_] No
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3. What is the number of eligible providers participating in MU
payments?
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4. What is the number of eligible providers in participating
health centers?
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DATA QUALITY AND REPORTING - COHORT 2 (FY 2016)
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1. Does the participating health center electronically extract
data from an EHR to report all UDS Clinical Quality Measure data
on all of their patients?
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[_] Yes [_] No
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2. Does the participating health center generate quality
improvement reports at the site and clinical team levels?
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[_] Yes [_] No
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3. Does the participating health center integrate data from
different service types and/or providers (e.g., behavioral health,
oral health)?
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[_] Yes [_] No
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HEALTH INFORMATION EXCHANGE (HIE) AND POPULATION HEALTH MANAGEMENT
- COHORT 2 (FY 2016)
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1. Does the participating health center improve care coordination
through health information exchange with unaffiliated providers or
entities?
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[_] Yes [_] No
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2. Does the participating health center use health information
exchange to support population health management?
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[_] Yes [_] No
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QUALITY IMPROVEMENT - COHORT 1(FY 2012 AND FY 2013) AND COHORT 2
(FY 2016)
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1. Does the participating health center improve the value,
efficiency, and/or effectiveness of health center services?
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[_] Yes [_] No
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PROMISING PRACTICES - COHORT 1(FY 2012 AND FY 2013) AND COHORT 2
(FY 2016)
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Narrative (voluntary):
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THE HEALTH CENTER CONTROLLED NETWORK WILL COMPLETE THIS SECTION
FOR THE ONE-TIME FINAL REPORT Cohort 1(FY 2012 and FY 2013) and
Cohort 2 (FY 2016)
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CUSTOMER SATISFACTION:
CHALLENGES AND BARRIERS:
LESSONS LEARNED:
CONTINGENCY PLANNING:
PROMISING PRACTICES:
ADDITIONAL COMMENTS:
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Public
Burden Statement: An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB
control number for this project is 0915-0285. Public reporting
burden for this collection of information is estimated to average
25 hours per response, including the time for reviewing
instructions, searching existing data sources, and completing and
reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to
HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39,
Rockville, Maryland, 20857.
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